The app reviews on this page were written by Steven Zuckerman, MD, physician editor-in-chief of MDNG: Neurology Edition.

	How would you like to be able to read minds, tell the future, or even control the thoughts and actions of someone else? Well, there is an app for that. Strictly speaking, iForce doesn’t really give you these abilities, but you sure can demonstrate the appearance of predicting the future or controlling thought (and perception is reality, so…). As physicians, we have specialized knowledge and understanding of the processes of brain function. Shouldn’t we be able to translate that information into extraordinary cognitive and cerebral abilities? Even though this application is not really a medical app, it can be presented in such a way that people are more likely to believe in your medical abilities. In fact, the performance of magic has its roots in the shaman, or medicine man, performing supernatural feats as a way of gaining acceptance of their healing powers. I am not suggesting you resort to this technique in your individual practice, but the CPT code for this effect is available on request.

	iForce is an app that uses your iPhone (or iPod Touch or iPad) to successfully reveal your prediction of a spectator’s freely selected option. They can think of any type of item you choose, for example a number from one to eight or their favorite type of food. You write a prediction on the iPhone, and after they indicate their selection, you show them that you had successfully predicted the correct answer (or read their mind in order to get the correct information).

	Of course, I can’t reveal how this is done (or I’d have to kill you). However, the method is absolutely ingenious. In fact, there is more than one way this can be accomplished using the program, making the likelihood that a spectator will figure out the method next to impossible. This app allows you to perform such a strong impression of your abilities that there was even a conspiracy among magicians to keep this program from becoming popular on the app store; they submitted one-star ratings to skew the results of the average rating seen by potential buyers to discourage purchases (see this 

 by tech columnist and magician David Pogue.

	So, if you are not averse to having a little fun with your patients or friends, I would highly recommend iForce as the best magic app, and possibly the best overall app that exists.

Why any interest in a note-taking application? In my case, it is because I vacillate between resolving to type my progress notes in the exam room as the patient is providing the history versus doing my notes later, when the patients have all been seen. I like to take handwritten notes to refer to later during transcription, but with an electronic medical record, paper notes don’t stay with the charts. So, if there is a digital form of my notes, it can be inserted into the record, or at least filed in such a way that I can always access those notes. My particular EMR does have a “jotter” function, which allows me to use a graphic board as an input device so I can scribble notes, but it is somewhat awkward. Using my iPad and a stylus, I can write on the iPad and attach the digital file to the patient chart when I am in my “dictate notes later” mood. Yes, I am using the iPad as very expensive scratch paper, but isn’t that what technology is ultimately for—taking a simple, inexpensive process and converting it into something complicated and costly?

	This is a simple note-taking program that functions very well. Notes are organized into notebooks, allowing you to separate all of one day’s patients into a notebook. Writing with the stylus is easy, and the handwriting is accurate (unfortunately, the program does not make your particular handwriting more legible). You can transfer either an individual note or an entire notebook to your computer via e-mail. There are no options regarding ink color or pen size, but you can make the paper appear on your iPad as graph paper, lined paper, or plain paper. For simply recording your notes during a patient visit, this program provides all of the functionality you will need, with a simple interface.

	This is a more sophisticated program that simultaneously records audio and time-synchs that file to your note taking. Afterward, if you want to review what was being said at the time you wrote your note, all you have to do is tap on the digital writing or picture, and the audio portion recorded at that time replays. These features make this a useful education tool, but there is no need to do this from any medical standpoint. Besides the synchronization of notes and audio, there are several options available in this program that are not included in Penultimate. Foremost among these is the ability to type the notes. Of course, if I were comfortable typing I wouldn’t need this program in the first place. In addition, files can be transferred to your computer both by e-mail and directly from within the same wireless network, thus avoiding any e-mail security concerns. However, on my first attempts at transferring files, the system did not work, so I cannot certify that the transfer of files will take place successfully. Also, the handwriting program does not “smooth” as well as Penultimate and requires you to be more deliberate in your writing.

	For a simple interface and easy note-taking abilities, I prefer the Penultimate App. However, for a business meeting or lecture situation, the AudioNote capabilities are attractive.

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Feature Articles

Physician-written reviews of medical apps for the iPhone, Android, and other platforms.

App Wrap: Mobile Medical App Reviews

Telehealth technologies are rapidly gaining acceptance among physicians in a variety of specialties and practice settings who realize that these tools allow them to provide high-quality, affordable, accessible care to patients.

Infectious Disease Specialists (IDS) of Sioux Falls, SD

, began offering telemedicine services to patients. A regional referral center in a rural section of the country, IDS provides consultation through referrals received from several major regional hospitals. Back then, physicians at IDS conducted about five telehealth visits per month. Today, they conduct hundreds.

	“There aren’t too many things in life that everybody likes, but [telemedicine] is one of them,” says Aris Assimacopoulos, MD, founding partner of IDS. “It has grown to be a huge part of our practice.” Assimacopoulos acknowledges that there is definitely a learning curve with telemedicine, and success requires the right mindset, but he says that “except for our actual physical presence at the hospital, we think it’s exactly like we’re there.”

	It’s difficult to deny the benefits of establishing a telehealth or telemedicine program in a medicalpractice. For the purposes of this article, the term telehealth refers to the monitoring of patients at home for changes in vital signs such as blood pressure or blood glucose levels; telemedicine refers to any program that involves a physician advising or consulting by televideo contact. Both approaches enable physicians to extend their services in an efficient and cost-effective manner. Instead of asking a patient to come into the office or sending a nurse to the patient’s home, a physician can use telehealth technology to monitor a patient’s blood pressure using biometric monitoring devices and adjust medication as necessary.

	How can physicians get started? Marilyn Dahler, RN, a consultant with the 

Great Plains Telehealth Resource and Assistance Center

, says that before they invest in this technology, physicians need to have a plan; they need to figure out how telehealth or telemedicine fits into the way they deliver care. They must decide who among their patient population they want to reach using these tools. For example, a rheumatologist might choose to see a patient in person the first time and then conduct follow-up consultations via telemedicine. Eric Rackow, MD, president and chief executive officer at 

, an organization dedicated to managing the care of people at home, agrees and points out that it’s best to start by identifying where in your practice telemedicine services can be most helpful.

	“I would start by identifying your chronically ill patients who have more complicated problems, so that you’re really doing something that is cost effective,” Rackow says. “Other patients can get to the office and see you, but it’s much more difficult for people with chronic conditions or any type of disability.” However, he cautions not to rely 100% on telemedicine. “You need to periodically have inperson visits to make sure things are in order.”

	Dahler also cautions physicians who are interested in starting a telemedicine program that they have to walk before they can run. Your clinic staff may be well trained and understand your expectations, but when you use telemonitoring, “you’ll be working with a remote site that may not understand those expectations; they will have to learn how to meet your needs with patients. So, it’s important to start out slowly, get all the bugs worked out of one application, and then move forward as you become more comfortable with the process,” Dahler says.

	The costs associated with setting up a telehealth or telemedicine program depend on many factors, according to Dahler. They vary based on the unique requirements of the practice. For example, a psychiatrist might need nothing more than an encrypted video program that allows him or her to reach out to a remote site. A perinatologist, however, might be concerned with the cost and availability of ultrasound equipment. However, the physician’s end of the connection—as opposed to the remote site&mdash;is often less expensive to implement.

	“At the physician end, you just need the tools to communicate with the remote site,” where the patient is located, Dahler says. “That can be done through a high-speed DSL. If you’re part of a health care network, they might have an existing infrastructure in which you can participate. The greater expense usually occurs at the remote site, where they have to have the examination camera and other equipment.”

	Rackow says that first implementing a telehealth monitoring program is probably the least expensive way to start; there are many companies that provide this service at a cost-effective rate, usually charging a per-month fee. “You could do it yourself and buy your own technology, but that would be too expensive,” he says. “In general, the charges from telehealth providers range from about $30 to $60 per month.”

	The alerts and data collection functionality at the heart of telehealth technology make these systems ideal for managing patients with serious chronic conditions, such as cardiovascular disease. Physicians can remotely monitor the blood pressure of a person who is hypertensive, or the weight of a congestive heart failure patient, knowing that the company providing the service records all the information. “If there’s a red flag, the company will notify you,” says Rackow. “It’s the simplest way for the physician to extend his or her office into the patient’s home.”

	Likewise, training is not a major issue. Dahler says that “patient care is patient care, whether it’s received in person or done electronically,” and most physician offices already have practices in place to monitor the quality of incoming information. She explains that in a normal telehealth homecare situation, as long as everything is going smoothly, there’s generally no communication between patient and physician. However, if a congestive heart failure patient gains four pounds and is not feeling as well as they normally do, that would trigger a communication to the attending physician. “That information would come into the practice the same way any other concern or alert would. It’s just a matter of recognizing that this is additional information that needs to be handled.”

	When Patricia Avila, MD, a preventive medicine specialist, was running her busy San Diego-based practice, she had to learn how to manage her patient population using paper and pen. “I always said to myself, ‘There’s got to be an easier way.’ If there was something that would allow me to become more efficient, I knew I would try it,” Avila says.

	After more than 20 years in southern California, Avila moved to Hawaii to establish women’s health programs at a local hospital. Shortly thereafter, she was recruited to become medical director for care management at the 

, the local Blue Cross Blue Shield organization, and was told they would be investing in 

American Well’s Online Care Personal Edition software platform

 to bring healthcare services online. “I thought, ‘Wow, that’s something I’ve been looking for.’ But I was wondering, ‘How is it going to work? And am I really going to use it?’”

	With the Online Care Personal Edition, doctors can make themselves available for online and phone consultations at any time, from any location, and for as long as they choose. No infrastructure is necessary, says American Well CEO Roy Schoenberg, MD. If you have a Web browser, you’re set, and there is absolutely no cost to the physician. “The services are being made available to physicians by their health plans or hospitals, whichever organization they are affiliated with.”

	Avila not only jumped in, she set up her own practice in her community “to reinvigorate myself with patients again, and to learn the new tools and see if they really worked, given my background in population management in large group practices.” Once she got over the psychological barrier of using the technology, the program was very intuitive. And her patients responded as well. “As they get older, it’s very difficult for seniors to get to their doctor’s office,” she explains. “And sometimes, we don’t need an office visit just to clear up some medication issues and do renewals. We can do that online.”

	Assimacopoulos says the telemedicine program IDS implemented seven years ago has been received equally well by all parties and that he hasn’t heard any complaints. Patients love it because they don’t have to travel several hours in order to see him. They can have x-rays and lab work done at their home clinic or hospital. The referring hospitals like the program because, especially where outpatients are concerned, they retain the revenue associated with procedures and tests. And then there’s the public relations value. “Patients know that if they go to their hospital they’re going to get essentially the same specialist care they would in a referral center. That’s extremely valuable,” Assimacopoulos says.

	The telemedicine program has also supplied a revenue boost for IDS. Assimacopoulos explains that where infectious diseases such as HIV are concerned, “when patients need us, they need us right now. You can’t say, ‘Schedule that patient to see me.’” In addition, infectious disease physicians—especially those in remote locations&mdash;are often deluged with phone calls from local medical professionals asking for advice. If the ID physician won’t take the call, they might lose the referral. If they take the call and provide advice, there’s no reason for patients to make an office visit. “That’s actually a huge revenue loss. So for us, the telemedicine program actually improved our revenue and decreased the amount of headache phone calls we would receive. We’ve been able to see those patients, offer an option, and still get reimbursed for providing that care,” he says.

	There are always legal issues to be aware of where patient care is concerned, and providing services via telemedicine is no exception. The most common, according to Tara Kepler, an attorney with 

, is the issue of licensure for physicians, nurses, and other practitioners. “There are regulations at the state level for all different practitioners now,” Kepler says.

	Licensure becomes an issue when practitioners attempt to reach across state boundaries. In most cases, physicians are required to be licensed in the state where the patient resides—sort of like the doctor making a house call to the patient. A minority of states require full licensure to practice telemedicine, whereas others don’t even define their jurisdictions. “If you’re just consulting another physician or offering a second opinion, most states have exceptions for that. But the safest rule is to analyze it state by state,” says Kepler. That includes knowing your patients. When physician clients want to set up a telehealth practice, Kepler says the first thing she asks is “Where are your patients physically going to be located?” She says that the overriding issue is quality of care; “We know how to provide it in person, but do we really know the risks when you start doing it virtually?”

	Kepler says that some states have heightened medical record documentation requirements solely because the service is being provided through telemedicine. Many states also have special hospital licensing requirements—local hospitals or clinics where the patient is located may require physicians who provide telehealth services to be credentialed on their medical staff.

	There often are heightened informed consent standards with telehealth. “There’s additional informed consent you must give a patient because the service is being delivered solely through telemedicine. There’s a lot more risk involved in what you’re doing simply because it’s being done through technology. And that can be unique to the type of service provided, such as with radiology, because things do look different on a screen, and images being transmitted electronically can lose some resolution,” Kepler says. There are many regulations that kick in when medical services are provided through telemedicine. As such, a good rule of thumb for physicians is to know their state requirements, as well as those of other states they may be reaching into.

	The feeling across the healthcare landscape is that support for and interest in telehealth and telemedicine is growing. Assimacopoulos says, “The potential for this is completely untapped.” Others recognize that as well. American Well, to complement its Online Care Personal Edition, released a Team Edition during the first quarter of 2010. This iteration allows providers to deliver coordinated care by collaborating with one another on behalf of a patient. Schoenberg gives the example of a primary care physician who decides that his or her patient needs to see as cardiologist. “Instead of sending the patient through a lengthy referral process, they can use the system on their desk to bring a cardiologist into that conversation that they’re now having with the patient in the office. What that does is it literally brings specialty care into primary care practices, making the primary care physician the coordinator of care for the patient,” he says.

	Assimacopoulos can’t imagine going back to the time when his practice didn’t provide services via telemedicine. “I’m actually concerned that if we ever got to the point where we didn’t have the resources to do it, I’d probably have to spend three or four hours on the phone answering questions from all types of physicians who have seen our services and now value them.” Avila feels the same way, “I now have more face-to-face, engaged time with my patients who really need it. It really is a very rich experience.”

Telemedicine Standards and Guidelines from the American Telemedicine Association

	Visit this site to download practice guidelines on the use of two-way, interactive videoconferencing to deliver health care services, an evidence-based tool designed to “aid practitioners in meeting the practice guidelines set forth in the guidelines document for providing appropriate mental health services via telehealth technologies,” and other useful recommendations on the use of telemedicine in practice.

CMS Proposed Rule Regarding Credentialing and Privileging of Telemedicine Physicians and Practitioners

	Read more about the proposed CMS rule affecting the conditions of participation for hospitals and critical access hospitals regarding the credentialing and privileging of telemedicine physicians and practitioners.

	“Widespread implementation of telehealth could 

[annually] just from reducing transfers of patients from one location, such as a nursing home, for medical exams at hospitals, physicians’ offices, or other caregiver locations.”

 -- from THE TELEHEALTH PROMISE - Better Health Care and Cost Savings for the 21st Century

Ed Rabinowitz is a veteran healthcare journalist based in Upper Mt. Bethel Township, PA.

Cover Story

Telehealth technologies are rapidly gaining acceptance among physicians in a variety of specialties and practice settings.

Reach Out and Touch Someone: Extend Your Practice Reach with Telemedicine

	Stop me if you have heard this one before: we’re coming up on yet another deadline for major Medicare payment cuts, a deadline that was delayed months ago by a Congress that chose to kick the can down the road (again) and enact a temporary fix to the sustainable growth rate (SGR) formula rather than do the heavy lifting and make the hard choices that a permanent solution would require.

	This is the ninth or tenth time in the last decade that Congress has taken the easy way out and avoided its responsibility to ensure that physicians receive equitable reimbursement for their services and Medicare patients continue to have access to health care services. These delays and temporary “doc fixes” only serve to create an uncertain business and practice environment, making it difficult, if not impossible, for practices to make meaningful financial plans and budgets beyond the next arbitrary deadline.

	This congressional inaction is having real repercussions for practices and patients across the country. Hospitals and practices are being forced to make the hard financial choices evaded by Congress and reevaluate the extent of their participation in Medicare. A recent survey by the Medical Group Management Association revealed the extent to which the lack of a permanent fix to the SGR formula is hurting practices and patients. Covering more than 2,800 practices including independent medical practices, hospitals, integrated delivery systems, medical practices owned by hospitals, academic clinical science departments, and other organizations representing more than 63,000 physicians, the MGMA survey sought to determine the effect of the upcoming Medicare payment cuts on access to care and practices’ ability to conduct business and plan for the future

	 When asked “as a result of the uncertainty created by the June 1, 2010 Medicare Part B payment reduction of 21.3 percent, later reversed by Congress, which decisions did your practice implement in June?” 12% of respondents said that they had stopped accepting new Medicare patients altogether. Forty-five percent said that they reduced the number of appointments for current or new Medicare patients. Thirty-two percent of practices said they had reduced the number of administrative support staff, 27% reduced the number of clinical staff, and more than 45% of practices said they had reduced physician and/or staff salaries and benefits. More than one-third of practices said they had put off purchasing an EHR or other health IT tools.

	Physicians, staff, and patients are already feeling the effects of the delay to find a permanent fix to the SGR formula, and I’m afraid it’s only going to get worse. The MGMA survey revealed that the current cutbacks may only be the tip of the iceberg: more than two-thirds of survey respondents said they are considering further limits to the number of new Medicare patients they see, nearly half said they are thinking about refusing to accept any new Medicare patients, and nearly 28% said they may stop seeing all Medicare patients. Large majorities are considering reducing support and/or clinical staff, delaying increases in physician and/or staff salaries and benefits, and delaying the purchase of new equipment.

	I agree with MGMA President and CEO William F. Jessee, MD, who said that “the concrete actions already taken by medical groups as a result of the uncertainty created by congressional inaction have added significant barriers to quality care… Uncertainty about the future is creating an unsustainable environment for many who practice in areas with large Medicare populations.” Faced with the looming threat of a 23% Medicare payment cut on December 1, followed by an additional 6.5% reduction on January 1, 2011, it seems that the best physicians’ can hope for right now is yet another extension by the current lame duck Congress. Then it will be time once again for physicians and their professional societies to try and convince a new slate of legislators to put the can away once and for all and find a permanent solution to this problem.

Editor's Note

Congress has failed yet again to devise a permanent solution to fix the sustainable growth rate (SGR) formula.

October 2010

App Wrap: Mobile Medical App Reviews

Reach Out and Touch Someone: Extend Your Practice Reach with Telemedicine

Are You Tired of Playing Kick the Can?